Hepatocellular carcinoma patients who have HIV do just as well after a liver transplant as those who are not infected, French researchers reported.

Action Points

Explain that a single-center French study in HIV-positive and -negative patients with hepatocellular carcinoma found that those undergoing a transplant had similar survival and recurrence rates regardless of HIV status.

Point out, however, that HIV-positive patients had a higher dropout rate while on the transplant waiting list so that survival was lower for HIV-positive patients on an intent-to-treat basis.

Hepatocellular carcinoma patients who have HIV do just as well after a liver transplant as those who are not infected, French researchers reported.

But on an intent-to-treat basis -- when survival is measured for all patients listed for transplant -- those with HIV do significantly worse, according to René Adam, MD, PhD, of Hôpital Paul Brousse in Villejuif, France, and colleagues.

That's mainly because they tend to drop off the list before the procedure, Adam and colleagues reported in the February issue of Hepatology.

"Our study showed that HIV infection impaired the results of liver transplantation on an intent-to-treat basis," Adam said in a statement, "but exerted no significant impact on overall survival and recurrence-free survival following transplantation."

Liver transplant is the definitive treatment for end-stage liver disease and despite some initial reluctance, physicians have come to embrace the procedure for people with controlled HIV, Adam and colleagues noted.

But the impact of HIV infection on outcomes for hepatocellular carcinoma patients who are getting a liver transplant has not been clear. To address the issue, Adam and colleagues conducted a single-center study in France, which they said is the largest to date.

All of the HIV-positive patients were treated with highly active antiretroviral therapy and had never had an AIDS-defining event or an opportunistic infection before they were put on the waiting list for transplant.

The main endpoints of the analysis were the dropout rate, reasons for dropout, overall survival after listing, and overall survival and recurrence-free survival after transplant.

The HIV-positive patients were younger than HIV-negative patients, with a median age of 48, compared with 57 (P<0.001) and had a higher alpha-fetoprotein level, with a median of 16 micrograms per liter, compared with 13 (P=0.04).

Nearly one-fourth of HIV-positive patients (23%) dropped out before transplant, compared with 10% of noninfected patients, but the difference did not reach significance.

Nevertheless, the dropout rate impaired survival: In HIV-positive and HIV-negative patients, survival rates after being put on the transplant list were 81% at one year and 55% at three years, compared with 91% and 82%, respectively. The differences were significant at P=0.005.

There were no significant differences in the pathological features of the cancer between the 16 HIV-positive patients and 58 HIV-negative patients who had a transplant.

After transplant, the researchers found:

Overall survival at one year was 81% in HIV-positive patients, compared with 93% in HIV-negative patients. The difference was not significant.

At three years, overall survival was 74% in HIV-positive patients and 85% in HIV-negative patients. Again, the difference was not significant.

Similarly, recurrence-free survival rates at one and three years after transplant were not significantly different -- 69% at both times in HIV-positive patients, compared with 89% at one year and 84% at three years in HIV-negative patients.

Patients with HIV who dropped out before transplant had significantly higher alpha-fetoprotein levels at the time of listing than those who went on to have a transplant -- 98 micrograms per liter, compared with 12 -- but no such difference was found among HIV-negative patients.

Evidence also has suggested that an important factor predicting recurrence after a transplant for hepatocellular carcinoma is an increase in the level of alpha-fetoprotein of more than 15 micrograms per liter per month while on the waiting list, the researchers noted.

"Our study confirmed the importance of this preoperative factor," Adam said. He and his colleagues argued that it will be important to monitor alpha-fetoprotein levels during the waiting period for transplant in order to detect those likely to drop out or to have a recurrence.

But, Adam said, "there are no objective arguments to contraindicate liver transplantation in this group if strict criteria are used for selection and patients are closely monitored until surgery."

The researchers did not report external support for the analysis. They said they had no conflicts to report.

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